Primary Aldosteronism and Public Health: New Definitions, New Challenges

The article, “Primary Aldosteronism: Are We Missing the Wood for the Trees?” [1], to which Piaditis et al. refer [2], makes a series of 5 points. The first is that on the current estimates on the prevalence of hypertension, and of primary aldosteronism in hypertension, in no country worldwide are more than 1% of patients with primary aldosteronism diagnosed and treated. The second is that to diagnose primary aldosteronism in the remaining >99% of patients, and then appropriately manage them, is way beyond the available health care resources in any country. The third is that primary aldosteronism has a risk profile, in terms of atrial fibrillation, stroke, and nonfatal myocardial infarct, far higher than age-, sex-, and blood pressure-matched essential hypertension [3]. The fourth is that mineralocortoid receptor antagonism is safe, efficacious, and uniquely vasoprotective in essential hypertension when titrated to effect [4] [5], specifically blood pressure lowering in resistant hypertension [6], and potentially game-changing in occult primary aldosteronism. The final point is the logical conclusion drawn from the first four – that a low dose mineralocortoid receptor antagonist should routinely be part of first line therapy in newly diagnosed hypertensives.

• References

• 1 Funder JW. Primary aldosteronism: are we missing the wood for the trees?. Horm Metab Res 2012; 44: 251-253
• 2 Piaditis G, Pappa T, Markou A, Gouli A, Papanastasiou L, Kaltsas G. Response to the article “Primary aldosteronism: are we missing the wood for the trees?. Horm Metab Res 2012; in press
• 3 Milliez P, Girerd X, Plouin PF, Blacher J, Safar ME, Mourad JJ. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol 2005; 45: 1243-1248
• 4 Levy D, Rocha A, Funder JW. Distinguishing the antihypertensive and electrolyte effects of eplerenone. J Clin Endocrinol Metab 2004; 89: 2736-2740
• 5 Epstein M, Williams GH, Weinberger M, Lewin B, Krause S, Mukherjee R, Patni R, Beckerman B. Selective aldosterone blockade with eplerenone reduced albuminuria in patients with type 2 diabetes. Clin J Am Soc Nephrol 2006; 1: 940-951
• 6 Calhoun DA. Low dose aldosterone blockade as a new treatment paradigm for controlling resistant hypertension. J Clin Hypertens (Greenwich) 2007; 9: 19-24
• 7 Gouli A, Kaltsas G, Tzonou A, Markou A, Androulakis I, Ragkou D, Vamvakidis K, Zografos G, Kontogeorgos G, Chroussos PG, Piaditis G. High prevalence of autonomous aldosterone secretion among patients with essential hypertension. Eur J Clin Invest 2011; 41: 1227-1236
• 8 Pappa T, Papanastasiou L, Kaltsas G, Markou A, Tsounas P, Androulakis I, Tsiavos V, Zografos G, Vamvakidis K, Samara C, Piaditis G. Pattern of adrenal hormonal secretion in patients with adrenal adenomas: the relevance of aldosterone in arterial hypertension. J Clin Endocrinol Metab 2012; 97: E537-E545
• 9 Markou A, Pappa T, Kaltsas G, Gouli A, Mitsakis K, Tsoounas P, Prevoli A, Tsiavos V, Papanastasiou L, Zografos G, Chrousos G, Piaditis G. Evidence of autonomous aldosterone secretion in a cohort of normotensive individuals: a very high odds ratio for progression into arterial hypertension (under review).
• 10 Funder JW. Ultimately we are in furious agreement.. J Hypertens 2012 in press